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Paradox of the Deteriorating Risk/Benefit Ratio of Increasing Surgical Volume…for the Surgeon

Saturday, January 3, 2004

The cardiac surgical outcomes literature is replete with studies documenting the improving risk/benefit ratio of increasing surgical volume for patients. Such studies have been used to justify minimum standards of operative cases for accreditation of cardiac surgical programs. Indeed, it is appropriate for those studies to focus the patients' results - that is why we are cardiac surgeons. However, the impact of increasing surgical volume on the surgeon is rarely addressed, probably because so few people would care about the result!

Having practiced cardiovascular surgery for over 25 years, I have come to the conclusion that each current case brings with it relatively more risk and less benefit for me than when I began practicing my specialty. This is not to be misconstrued that I derive no benefit from each operation, rather the relative benefit seems less, while the concurrent risk seems greater. I have interviewed several senior colleagues in various surgical specialties and have found that this observation seems almost universal. While I will largely discuss my own situation, most of them voiced similar feelings.

Allow me to try to explain my perception of this phenomenon. Let's begin with some observations about the benefits that accrue with each case as the surgeon starts in practice after residency. When a surgeon begins clinical practice, most cases are associated with positive anticipation. The operation may be either entirely new for the surgeon and thus a wonderful learning experience, or the numbers of previous, similar cases are few enough that there is something valuable to be learned. Some have claimed that cardiac surgeons often learn more in their first year out in practice than they did in their entire residency. The learning curve is often very steep and, thus, very fulfilling.

After a successful operation, cardiac surgical residents in training are rarely the recipients of the patient's and family's goodwill, which obviously is usually directed to the staff surgeon. As he starts practice, this appreciation from patients and families becomes crucial to making his experience positive. Not infrequently families will comment on how wonderful it must be for a surgeon to be able to perform such miracles at such a young age. This is powerful stuff for a budding clinical surgeon!

What about the relative risks as one begins practice? Referring cardiologists, if they are understanding, will often allow a new surgeon a little more leeway in his results and accept some complications that they might not from more senior colleagues. After all, they know that the learning curve applies to virtually all technical endeavors (even interventional cardiology!). Admittedly some young surgeons, particularly in private practice, are heavily scrutinized, but they may not appreciate that it is happening!

Another feature of perceived risk is based on the young surgeon's lack of experience, which can be an emotional blessing. Very active, senior, clinical surgeons have seen complications with even the easiest cases and know that trouble can be just around the corner. Younger surgeons often do not appreciate the potential consequences of seemingly minor technical mistakes - the suture that is a little too deep in the coronary wall, the bypass conduit that is a little tight, the prosthetic valve that may by just a little big for the annulus - because so often they do not result in complications. Thus, the young surgeon frequently does not accurately perceive the potential risk of minor errors. (Unfortunately this state of bliss can be rudely interrupted with the first occurrence of some complication the young surgeon has never seen and may not know how to handle.)

Let's see how this level of perceived risk changes over time. As the clinical surgeon builds his practice and his results become known, he generates an anticipated, expected level of performance. If he has become skilled, that bar can be set very high. The height of that bar is set not only by referring cardiologists and patients, but, most importantly, by the surgeon himself, that is, if he is honest with himself. The expectation climbs and reaches a level not truly different from that expected of Pedro Martinez when he pitches for the Red Sox or of Michael Schumacher when he drives his Ferrari in a Formula One race. The experienced cardiac surgeon is not expected and does not expect to lose. (One obvious failure in this analogy is that when an athlete fails, he or his team suffers, though rarely fatally. When a surgeon fails, the patient suffers, too often fatally.)

As a surgeon becomes more experienced, which also means having seen more and different complications than he ever imagined were possible, he knows the capriciousness of surgical complications. After some otherwise successful operations, I have found myself worrying about the one stitch placed in a coronary anastomosis that was off by a fraction of a millimeter. The rest of the three hours, fifty-nine minutes and thirty seconds of good performance do not even register in my thoughts. I may sit waiting for my pager to beep or lie awake at night waiting for the phone to ring bringing me the information that the patient has new ischemic changes on the electrocardiogram in the distribution of that stitch. The beeper rarely goes off, and the call rarely comes, but I know from experience what can happen. (I also believe in the cumulative negative impact of carrying a pager virtually 24 hours a day, every day, for years.)

A similar phenomenon I have noticed is that I can vividly recall the details of my patients who have died or suffered major complications, while I may not even recognize the names of patients who have had an uncomplicated, successful hospital course. While all surgeons agree that every operative procedure has definable risks, we usually have difficulty accepting them in any of our own patients. This business of self-evaluation can be very humbling in a profession that is not supposed to be associated with that term.

Thus, the perception of increasing risk with each operation later in a surgeon's career has some foundation, often created by the surgeon himself. The senior surgeon also knows that no matter how careful he is in the operating room or in dealing with patients and their families, an accusation of negligence is lurking behind each complication. He also frequently knows from experience that it is impossible not to take a lawsuit personally.

I will not dwell on the deteriorating financial remuneration that has swamped our specialty, except to observe that salary growth is also greatest in the early years, adding to the young surgeon's positive feelings. For some senior surgeons, the bar of standard of living outside the hospital was also raised so high that they now have difficulty dealing with the current financial collapse of our specialty, which in turn can impact their perceived benefit of each operation.

But what of the benefits as one becomes more senior? Positive response from patients and families remains a prime, motivating force. Subsequent referrals from satisfied patients' families and friends are very rewarding. One new benefit is the gratification of building and nurturing a team of professional friends that reliably produce excellent results in most patients. There are some new operations to learn and unusual pathologies to treat, but they are relatively much less common. The learning curve flattens. Indeed all experienced surgeons must admit that routine cardiac surgery can become a little boring, lacking the technical and intellectual challenges of our early years. Added to the loss of challenge in each case is frequently the loss of focus on the individual patient in favor of cumulative results in a series of patients with the same procedure.

So the perceived risk increases while the perceived benefit decreases for each operation as a surgeon's operative experience grows. Is this pathologic or is it merely inevitable? I am hoping the latter is true; it will make it easier for me to complete my career, because I still love operating on hearts, which is the greatest privilege a surgeon can be granted.

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